Chronic Care/Chronic Disease Management Models for COPD
Chronic disease management programs addressing COPD may be based on the Chronic Care Model.
Components of this model include links to community resources, health system support, and self-management. The
structure and delivery of these types of program may vary, but they usually provide information about COPD,
offer education about behavior change, and provide information about medication adherence and management.
According to the Global
Initiative for Chronic Obstructive Lung Disease, self-management education – with coaching by a
healthcare professional – should be a component of this model.
Self-management. Based on a definition from a consensus of international experts,
“A COPD self-management intervention is structured but personalized and often multi-component, with
goals of motivating, engaging and supporting the patients to positively adapt their health behavior(s) and
develop skills to better manage their disease.”
Programs focus on education and behavior change, such as the adoption and maintenance of
health-promoting behaviors, and emphasize the patient's role in the active management of their COPD.
Self-management change seeks to improve physical and emotional health and quality of life, in addition to
minimizing COPD-related impairments. Strong partnerships with healthcare providers, caregivers, and loved ones
underpin effective self-management programs, particularly iterative communication to maintain patient motivation
and knowledge. These strategies typically originate in clinical settings, but remote connection options are
available through computers and mobile devices.
Action Plans. Self-management is particularly effective when patients develop action plans
outlining the steps that they will take to implement their strategies. These can be written or oral, based on
standard templates or tailored to each patient. This action plan drives patients to move beyond knowledge of
their self-management responsibilities and pushes them to think about how they will effectively change their
behavior. A 2016 systematic review suggests
that the development of COPD action plans is associated with reduced hospitalizations and emergency department
visits for COPD exacerbations, compared to patients who received usual care. Action plans can provide enhanced
benefits when supplemented by a short educational follow-up that supports patient plan adherence.
Examples of Chronic Care/Chronic Disease Management Program Models
Disease Self-Management is an evidence-based program developed by Stanford University. It consists
of a six-week workshop designed for people with multiple chronic conditions including COPD.
Genesis HealthCare System's COPD Readmission Prevention
Program in Zanesville, Ohio, uses a chronic disease care management approach to improve readmission
rates for COPD patients. Through the use of registered nurses serving as both navigators and tobacco
treatment specialists, the program is able to offer assistance to COPD patients throughout the continuum of
The American Lung Association's Better
Breathers Club connects people with various lung diseases to resources, support, and education.
Activities are led by trained facilitators and are offered nationwide.
Bridges to Care Transitions, a collaborative program led by Bay
Rivers Telehealth Alliance, offers remote home monitoring and chronic disease management coaching to
patients with chronic illnesses in rural Tidewater, Virginia. Patients enroll in the program at the time of
discharge from the hospital and participate in up to 90 days of remote home monitoring and coaching. The
program incorporates a variety of evidence-based models, including the Coleman model, the Healthy
IDEAS model, and Stanford
model for Chronic Disease Self-Management.
The Adventist Health System Quality Improvement
Project, based in rural Butte County, California, offers a variety of COPD services including medication,
education, smoking cessation, and infection prevention, including information about recommended vaccines.
The project was modeled on the evidence-based Reversible Obstructive
Airway Disease (ROAD) program from the University of California Davis Medical Center. COPD patients
are provided with treatment planning, case management, and one-on-one education.
The Sarah Bush Lincoln Health Center in
rural east central Illinois is using evidence-based efforts to improve the quality of life among COPD
patients and reduce hospital utilization. Program efforts focus on patient activation, self-management
behaviors, and medication management. The program uses motivational interviewing to assist patients with
Considerations for Implementation
Strong patient-provider relationships with clear communication are critical to successful self-management. Care
team members should ensure that they consistently support and encourage patients in their self-management
efforts in order to build confidence in their ability to successfully achieve their goals and to hold them
accountable to completing their action plans.
COPD is often accompanied by other chronic
comorbidities, such as diabetes, heart disease, lung cancer, osteoporosis, and mood disorders. Patients
with multiple chronic illnesses and comorbidities receive care
from various providers, which can result in disparate and fragmented care strategies. Since many COPD patients
present complex needs, chronic care models should seek to streamline various elements to improve quality of life
and minimize exacerbations. Successful streamlined care is dependent upon effective collaboration and
communication among different care team members and between the care team and the patient.
Program Clearinghouse Examples
Resources to Learn More
Disease Management in Rural Areas
Case descriptions of six rural health organizations that have implemented chronic disease management
Author(s): Zuniga, M., Bolin, J., & Gamm, L.
Organization(s): Southwest Rural Health Research Center
Offers a variety of tools helpful with managing COPD, including sample action plan in both English and Spanish
for patients to complete with his/her healthcare provider.
Organization(s): American Lung Association
Management Interventions for Patients with Chronic Obstructive Pulmonary Disease
A literature review of 26 trials evaluating the effects of an integrated disease management (IDM) intervention
for people with COPD.
Author(s): Kruis, A., Smidt, N., Assendelft, W., Gussekloo, J., Boland, M., Rutten-van
Molken, M., & Chavannes, N.
Citation:Cochrane Database of Systematic Reviews, Issue 10
Disease Self-Management Education in Rural Areas
Provides recommendations and resources for implementing chronic disease self-management education programs in
rural settings and includes success stories.
Organization(s): National Council on Aging